Is a mandatory intensive care unit stay needed after liver transplantation? Feasibility of fast-tracking to the surgical ward after liver transplantation

Abstract

The continuation of hemodynamic, respiratory, and metabolic support for a variable period after liver transplantation (LT) in the intensive care unit (ICU) is considered routine by many transplant programs. However, some LT recipients may be liberated from mechanical ventilation shortly after the discontinuation of anesthesia. These patients might be appropriately discharged from the postanesthesia care unit (PACU) to the surgical ward and bypass the ICU entirely. In 2002, our program started a fast-tracking program: select LT recipients are transferred from the operating room to the PACU for recovery and tracheal extubation with a subsequent transfer to the ward, and the ICU stay is completely eliminated. Between January 1, 2003 and December 31, 2007 , 1045 patients underwent LT at our transplant program; 175 patients were excluded from the study. Five hundred twenty-three of the remaining 870 patients (60.10%) were fast-tracked to the surgical ward, and 347 (39.90%) were admitted to the ICU after LT. The failure rate after fast-tracking to the surgical ward was 1.90%. The groups were significantly different with respect to the recipient age, the raw Model for End-Stage Liver Disease (MELD) score at the time of LT, the recipient body mass index (BMI), the retransplantation status, the operative time, the warm ischemia time, and the intraoperative transfusion requirements. A multivariate logistic regression analysis revealed that the raw MELD score at the time of LT, the operative time, the intraoperative transfusion requirements, the recipient age, the recipient BMI, and the absence of hepatocellular cancer/cholangiocarcinoma were significant predictors of ICU admission. In conclusion, we are reporting the largest single-center experience demonstrating the feasibility of bypassing an ICU stay after LT. Liver

Avoiding Stay in the Intensive Care Unit After Liver Transplantation: A Score to Assign Location of Care

“…Some LT programs have adopted the practice of early tracheal extubation, but few have tried bypassing the ICU altogether (5-10). We have previously published our experience with ''fast-tracking'' early tracheal extubation, recovery from anesthesia in the postanesthesia care unit (PACU) and transferring patients to the surgical ward after LT, completely eliminating an ICU stay (11). This practice has been consistently used in our program since 2002.…”

Critical Care Management after Adult Liver Transplantation

“…Birçok merkezde elektif KT uygulandığında hastalar operasyon bitiminde kardiyovasküler, solunumsal ve metabolik olarak stabilse ve ekstübasyon kriterlerini içeriyorsa ameliyathanede ekstübe edilip YBÜ'de izlenirler veya daha nadir olarak bazı merkezlerde olduğu gibi bir süre PABÜ'de izlendikten sonra servise çıkarılırlar (5,85). Uygun hastalarda gerçekleştirilen erken ekstübasyonun greft fonksiyonunu iyileştirdiği, YBÜ'de kalış süresini ve maliyeti azalttığı, nozokomiyal enfeksiyon oranını düşürdüğü gösterilmiştir.…”

“…Bazı yazarlar tarafından ameliyat sırasında stabil seyreden ve komplikasyon gelişmeyen hastaların YBÜ'ye alınmadan postanestezik bakım ünitesinde (PABÜ) izlenip direkt olarak servisteki odalarına transport edildiği bildirilmesine rağmen birçok merkezde hastalar entübe ya da ekstübe olarak YBÜ'ye alınır (5). Hastaların YBÜ'de kalış süresi preoperatif durumlarına, intraoperatif seyirlerine ve postoperatif komplikasyon gelişmesine bağlı olarak değişkenlik gösterir (6).…”

“…gelişmeler sonucunda KT sonrası ortalama YBÜ'de kalış süresi oldukça kısalmıştır. Bununla ilgili olarak 1994 yılında yayımlanan bir derlemede ortalama postoperatif mekanik ventilasyon süresi 36 saat, ortalama YBÜ'de kalış süresi 6 gün olarak bildirilirken günümüzde birçok kurumda komplikasyonsuz olgularda ortalama YBÜ'de kalış süresinin 24 saatin altına indiği, hatta bazı kurumlarda seçilmiş hastaların YBÜ'ye hiç yatırılmadan PABÜ'de izlenip stabillendikten sonra servise çıkarıldığı bildirilmektedir (5,7,8).…”

Potential catalysts in postoperative management/critical care

“…The concept of a "fast track," first advocated by Mandell and colleagues, 10 has been successfully applied in select centers with excellent outcomes. 11 Recently, Bulatao et al 12 have proposed a scoring system to predict successful fast tracking after LT. Although these efforts continue to evolve, the patient population upon whom fast tracking is based is a shrinking minority.…”